DVBCWNW3 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 30 MARCH 2005
;;2.7;AMIE;**93**;Aug 7, 2003
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Including Prior Treatment and Subjective Complaints):
;;
;; 1. Location and nature of the injury or disease.
;;
;;
;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
;; frequency, duration, response, and side effects.
;;
;;
;; 3. Subjective Complaints
;;
;; Comment on presence or absence of each of the following:
;;
;; a. Interference with breathing through nose.
;;
;;
;; b. Purulent discharge.
;;
;;
;; c. Dyspnea at rest or on exertion?
;;
;;
;; d. If speech impairment (ability to communicate by speech,
;; ability to speak above a whisper, etc.).
;;
;;
;; e. For disease or injury affecting soft palate, is there nasal
;; regurgitation or speech impairment?
;;
;;
;; f. For chronic sinusitis, indicate which sinuses are affected and
;; whether pain and headaches are present. Describe severity and
;; frequency.
;;
;;
;; g. If allergic attacks, frequency and baseline status between attacks.
;;
;;
;; h. Other symptoms noted.
;;
;;
;; i. Describe frequency and duration of periods of incapacitation
;; (defined as requiring bed rest and treatment by a physician).
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Perform complete examination of area affected by disease and/or injury.
;; Report all findings. Additionally, comment on presence or absence of each
;; of the following:
;;
;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
;; are present.
;;
;;
;; 2. For bacterial rhinitis: Indicate whether there is evidence of
;; granulomatous disease including rhinoscleroma.
;;
;;
;; 3. When there is obstruction (partial or complete) of one or both
;; nostrils, indicate percent of obstruction for each.
;;
;;
;; 4. Sinusitis - Describe tenderness, purulent discharge, or crusting.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
;; 3. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;
;;E. Diagnosis:
;;
;; Comment on whether the disease primarily involves or originates
;; from the nose, sinus, larynx, or pharynx.
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWNW3 2824 printed Apr 09, 2024@20:51:12 Page 2
DVBCWNW3 ;ALB/RLC NOSE, SINUS, ETC WKS TEXT - 1 ; 30 MARCH 2005
+1 ;;2.7;AMIE;**93**;Aug 7, 2003
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;
+4 ;;
+5 ;;B. Medical History (Including Prior Treatment and Subjective Complaints):
+6 ;;
+7 ;; 1. Location and nature of the injury or disease.
+8 ;;
+9 ;;
+10 ;; 2. Treatment - type,(i.e., surgery, medications, oxygen, respirator, etc.),
+11 ;; frequency, duration, response, and side effects.
+12 ;;
+13 ;;
+14 ;; 3. Subjective Complaints
+15 ;;
+16 ;; Comment on presence or absence of each of the following:
+17 ;;
+18 ;; a. Interference with breathing through nose.
+19 ;;
+20 ;;
+21 ;; b. Purulent discharge.
+22 ;;
+23 ;;
+24 ;; c. Dyspnea at rest or on exertion?
+25 ;;
+26 ;;
+27 ;; d. If speech impairment (ability to communicate by speech,
+28 ;; ability to speak above a whisper, etc.).
+29 ;;
+30 ;;
+31 ;; e. For disease or injury affecting soft palate, is there nasal
+32 ;; regurgitation or speech impairment?
+33 ;;
+34 ;;
+35 ;; f. For chronic sinusitis, indicate which sinuses are affected and
+36 ;; whether pain and headaches are present. Describe severity and
+37 ;; frequency.
+38 ;;
+39 ;;
+40 ;; g. If allergic attacks, frequency and baseline status between attacks.
+41 ;;
+42 ;;
+43 ;; h. Other symptoms noted.
+44 ;;
+45 ;;
+46 ;; i. Describe frequency and duration of periods of incapacitation
+47 ;; (defined as requiring bed rest and treatment by a physician).
+48 ;;
+49 ;;
+50 ;;C. Physical Examination (Objective Findings):
+51 ;;
+52 ;; Perform complete examination of area affected by disease and/or injury.
+53 ;; Report all findings. Additionally, comment on presence or absence of each
+54 ;; of the following:
+55 ;;
+56 ;; 1. For allergic and vasomotor rhinitis, indicate whether nasal polyps
+57 ;; are present.
+58 ;;
+59 ;;
+60 ;; 2. For bacterial rhinitis: Indicate whether there is evidence of
+61 ;; granulomatous disease including rhinoscleroma.
+62 ;;
+63 ;;
+64 ;; 3. When there is obstruction (partial or complete) of one or both
+65 ;; nostrils, indicate percent of obstruction for each.
+66 ;;
+67 ;;
+68 ;; 4. Sinusitis - Describe tenderness, purulent discharge, or crusting.
+69 ;;
+70 ;;
+71 ;;D. Diagnostic and Clinical Tests:
+72 ;;
+73 ;; 1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.
+74 ;; 2. If there is facial disfigurement, order COLOR PHOTOGRAPHS.
+75 ;; 3. Include results of all diagnostic and clinical tests conducted
+76 ;; in the examination report.
+77 ;;
+78 ;;
+79 ;;E. Diagnosis:
+80 ;;
+81 ;; Comment on whether the disease primarily involves or originates
+82 ;; from the nose, sinus, larynx, or pharynx.
+83 ;;
+84 ;;
+85 ;;Signature: Date:
+86 ;;END
